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Standing Committee on Health and Ageing
Adult dental services in Australia

FLOYD, Ms Jennifer Gai, Director, Oral Health Services, Western New South Wales Local Health District


CHAIR: Thank you, Ms Floyd, for being in attendance today. I think you met all of the committee earlier this meeting. We invite you to give evidence now. Although the committee does not require you to speak under oath, you should understand that these hearings are formal proceedings of the Commonwealth parliament. Giving false or misleading evidence is a serious matter and may be regarded as a contempt of parliament. I note from our earlier conversation what a big area Western New South Wales Local Health District is. Do you wish to make a brief introductory comment before we proceed to questions? I know that we have a submission here, and we would very much like to hear from you.

Ms Floyd : Yes, I would like to make an opening statement. I would like to thank the committee for the opportunity to appear today. Before I begin, I would like to acknowledge the traditional custodians of the land on which we are meeting today, the Wiradjuri people. I would like to extend my respects to the elders both past and present, including Aboriginal people present here today.

As outlined in our submission, Western New South Wales Local Health District is a part of the New South Wales health system. Our local health district stretches from Bathurst in the east to Bourke in the west, and there is a large area in between. Our patients live in regional, rural or remote communities, and we provide public dental services for both adults and children—in addition, of course, to the normal range of health services. This year the local health district received additional funding for dental services through the first NPA, and this has already had a positive impact, enabling us to provide more care for patients on our waiting lists.

While we would like to see a universal system for access to both preventive and basic dental care for all Australians, we also appreciate that this would come at a significant cost. It is unfortunate that dentistry has not been a part of the Medicare system and that, as a result, we see very significant differences in oral health across the community. Those who are the most disadvantaged and those who are vulnerable experience very poor oral health, and it is these people who need first priority when it comes to dental care funded by the states or the Commonwealth. For that reason, we believe very strongly in the NPA.

As outlined in our submission, a significant challenge in rural areas is ensuring there is an adequate dental workforce. I have lived and worked in this area all of my life, and over the last 10 to 15 years I have seen small towns that used to have a full-time private dentist who was very viable. But, as those people have moved or retired, the towns now have either no private dentist or only a part-time visiting service. In the public sector, we struggled for many years to attract dentists to our vacant positions, even to large regional cities like Orange and Dubbo. For almost five years, I could not recruit oral health therapists because so few were graduating in New South Wales. This is finally changing, I am pleased to say, with new dental schools like that of Charles Sturt University—and it is not the only one. We are seeing increased numbers of dentists and oral health therapists starting to graduate. In the past two years, I have been able to employ oral health therapists who grew up in country New South Wales, not so far from here, and who wish to continue to work in country New South Wales. Of course, this is how it should be. This is what we need. The success of undergraduate dental programs delivered in regional areas is fundamental to ensuring that regional and rural areas have the dental workforce that they need.

I think it is also important that dentistry programs remain within the reach of country students. Some dentistry programs are now full fee paying—they are not covered by HECS—and they are graduate entry only, meaning that the students have to have first completed another degree. Graduates from expensive courses who have had to study for at least seven years also have higher expectations of their future earnings. This is not good for the community, and we all know that affordability of dental care is a widespread problem in Australia.

One way of making dental care more affordable is better utilisation of oral health therapists in both the public and the private dental sectors. Oral health therapists only require three years of training but can provide a range of preventive and basic dental care services for patients. In our experience in the public sector, oral health therapists are more likely to work in the country, and they are more likely to work in the public sector.

I would like to speak specifically, though, about public dental services and their role not only as service providers but also in brokering and coordinating services through other providers. As a public dental service we certainly believe we are well placed to manage additional funding to ensure that those patients with the greatest need receive the services that the states and the Commonwealth can fund. We provide services for those with the lowest incomes and we prioritise access for those patients with the greatest clinical needs. This also takes into consideration if the patient is living with a chronic medical condition. I believe we are very innovative in the way that we provide services, and we work in partnership not only with the private dental sector through our vouchers but also with other not-for-profit organisations who can deliver services.

This building that the committee toured this morning and that we are very proud of, and what is happening from this building, is an example of an innovative partnership between Charles Sturt University, the local health district, the University of Sydney and now also the Royal Flying Doctor Service. We are working together not only to educate dental students and to help each other but also to provide a significant amount of dental care for the community. We have created a centre here where it has now become possible to recruit and retain staff, and we are developing innovative funding models with Charles Sturt University where our public dental patients can be seen by the students.

We also work in partnership with Aboriginal medical services in our region, and together with all of our partner organisations we aim to maximise the availability of services to our communities. We work together rather than in competition, and we avoid duplication. We are not driven by profit, and the community is always our first priority. There are many other examples of innovation and partnership. The Brewarrina student dental program is just one of which we are a partner. This program provides much needed dental care and valuable experience for dental students in a very remote setting. Only this week I met with Brewarrina Shire Council, Charles Sturt University and the Royal Flying Doctor Service to discuss how we can continue this valuable program because Griffith University is no longer able to send their students.

We believe that national partnership agreement funding through the states and territories is an appropriate investment in adult dental services. The states and territories have many years of experience in delivering public dental services and in working in partnership with other dental providers to deliver services. However, there are always concerns. Funding of dental services has been something of a political football now for many years, and it is difficult to plan for increased services when there is always underlying uncertainty about the volume of funding that might come through. There is a need also to understand that the delivery of services to rural and remote communities comes at an additional cost, and this must be recognised in funding models. To give just one example, the Brewarrina program that I just mentioned came at both capital cost, which the Commonwealth did fund, and at significant recurrent costs associated with getting the students and their supervisor to Brewarrina, accommodating them and operating a dental clinic in a remote setting.

The final point I would like to make, just in closing, is that the majority of dental disease is preventable. Under national partnership agreements, the Commonwealth should ensure that preventive dental services are not undervalued or forgotten. There is much that can be done to prevent dental disease by the states under the NPA that is not measured in item numbers or traditional dental activity, and it is important to invest now in prevention. It is essential to ensuring that the cost of dental care is manageable in the future. Thank you.

CHAIR: Thank you very much. For the record, I thank you for showing us around your fantastic facility here this morning. We were all very impressed to see the students working and to see how the community comes together with the university. We can see what potential this has to not only service this community but also be a model for other areas throughout Australia. I congratulate everyone who is involved here. We noticed how dedicated the staff were and your own dedication as well. Thank you very much.

When we went around this morning, we talked a little about the national partnership agreement, which you mentioned a moment ago. Just for the record, could you contrast the way the national partnership agreement will work with the way the previous, Chronic Dental Disease Scheme worked in relation to addressing the needs of public health patients and other patients within the community.

Ms Floyd : I would be pleased to talk about that. At the outset, it is important to understand that, whether it is the Chronic Dental Disease Scheme or the NPA, it is not enough money to provide all the dental care that all the people need. In that context, I think it is very important that the funding that is there goes to those who need it the most. In some cases, they are people with chronic diseases; in other cases, they are not people with chronic diseases but people who live in disadvantage and have terrible oral health.

Under the first round of the NPA for New South Wales, from February to June, we have mainly been issuing vouchers so that patients who are existing waiting list can go to private dental providers and can get dental care. In many cases for us, it is about dentures, because that is a significant unmet need at the moment. The voucher scheme is a very controlled scheme that has been in place for over 10 years. The dentists are not allowed to charge a co-payment. So, when we give a patient a voucher, they can go to the dentist or the dental prosthetist and they can get their dentures. The only way that they can be charged a fee is if they choose to have a metal denture instead of an acrylic denture. So, for patients who do not have the ability to pay a gap or to pay up-front, this is a way they can actually access dental care.

By comparison, under the Chronic Dental Disease Scheme, we know that many, many people in New South Wales got access to care. Some had a chronic disease but perhaps limited dental problems, some had significant chronic disease and some had very little chronic disease. It was very hard for us to see the true rationale for who was eligible and who was not. We certainly could not look at a patient and know whether or not they were eligible; we could only send them to their GP to find out. But what we found was that in our area, where we do not have an oversupply of dentists by any means, the majority of providers were still charging their normal fees, where the patient paid the fee and then went to Medicare to get their rebate. This can be a really significant gap for patients to pay, as the Medicare rebate might only be half of what they were charged.

The patients who are on our waiting list—and adults have to have a healthcare card or pension card to be on our waiting list, which is about 40 per cent of our adult population—just could not afford to engage in the chronic disease scheme and so they stayed on our waiting list and hoped that we would get to them sometime soon. Under the NPA, we have got to a lot of those patients quite rapidly. So I would say that the NPA is a way to actually make sure that services go to those patients who need dental care the most and who are least able to afford it.

CHAIR: Thank you very much. I have a couple of other questions, but I will let my colleagues ask some first.

Mr COULTON: How are you delivering the services to the more remote communities? Is the dental surgery at Gilgandra MPS one that is under your control?

Ms Floyd : The surgery itself is in the Multi Purpose Health Service, so it is under our control—although it was jointly funded by the state, the Commonwealth and the local shire council, so we have some agreements in place around utilisation. We send a public dentist to that clinic to treat public patients, but the private dental practice that operates from Narromine also sends over a private dentist on a weekly basis. And that practice participates in our voucher scheme; so, if our patient had a voucher and they lived in Gilgandra, they could access that private dental service locally.

Mr COULTON: What about places further out, like Lightning Ridge and other places like that? Do you have clinics out there which the dentist travels out to? What facilities are there on the ground which you provide the services through?

Ms Floyd : In some areas there are not enough services—we know that—whether it is public or private. As an example, Lightning Ridge has a part-time service but there are other towns that have no service at all or it varies from time to time. Generally speaking, from a public dental service perspective, the further we go out, if I can provide services to patients through vouchers because there is a private dentist there then that is our preference rather than sending out our own staff. Sometimes we need to send our own staff. I will use Bourke as an example. It is a large town. It supported a full-time dentist for many, many years. Now it has a range of drive and a fly-in fly-out services between us, POCHE Centre and the Royal Flying Doctor Service, but it still does not have the services that it needs and none of those services are private dental services. So my vouchers do not work in Bourke.

Mr COULTON: Who owns the clinic where they operate from?

Ms Floyd : It varies. In Bourke, it is the Aboriginal medical service. In Lightning Ridge, it is in the community health centre.

Mr COULTON: The Walgett ones?

Ms Floyd : Walgett is the Aboriginal medical service.

Mr COULTON: Just one more question—and I probably missed it: let us say I am a patient. I have a healthcare card and I need the treatment. How do I obtain the voucher? On whose say so do I get one?

Ms Floyd : In our area, you would ring our 1300 number for most patients. We do have some other ways of helping people access it who cannot ring that number. You would ring the number and you would talk about what your dental needs are. You would firstly be triaged, basically by a computer based system that would prioritise you. If you were asking for new dentures, we would endeavour to get you in for an appointment within three months, and then a dentist would assess your needs. We would prioritise you based on your dental needs. If you have dentures already, the state of those dentures and also your medical conditions would be assessed. That is how we decide. We see people in order on our lists but we do have different priority lists. So somebody who has a chronic disease that is seriously impacting on their general health and that will be impacted by their dental health will always get seen ahead of people who just need dental treatment.

Mr LYONS: You talked about the preventative dental services—I used to work in accounting, so I am sorry about my question before I ask it: how do you guarantee that we get value for money out of preventative health? The question is: how do you account for those services?

Ms Floyd : It can be very challenging because of the nature of some of the preventive dental services. For example, there is an item number for spending time on giving somebody instruction on how to brush and floss their teeth and it can be billed. If you look at the strict definition, certainly within my service, my staff know that if they are going to give tooth brushing instruction and count that item number they cannot give tooth brushing instruction while they are doing a filling; it has to be a separate activity. It is something separate that they do. It is their whole focus when talking to the patient. They would spend 10 to 15 minutes on that instruction and then they would count the item number. I do not know how you would actually monitor and control that across all sectors. It is a challenging area.

When I mention these things about prevention, it is not just about when a patient is in the chair; it could be when you go out to a community and talk to a group of new mums or to elders or to a diabetes support group. Those types of things do not have item numbers and they are very important activities that we need to engage in, but I do not think that they are really valued under the current NPA. I think that is a concern.

Mr LYONS: Is any work being done on how to count that stuff? Is there any research on it which you know of?

Mr LYONS: So is there any work being done on how you would count that stuff? Is there any research happening, do you know?

Ms Floyd : I think one of the problems is that item numbers that we use are based on the Australian Dental Association schedule of fees that has been in existence for I do not know how long—as long as I can remember—and it is a really valuable schedule of fees that we all use, but they were designed for private practice. We have added a few item numbers that we count in our own information system in NSW Health. For example, we have created an item number for when our clinicians do a chair-side smoking cessation brief intervention. But it does not go far enough and I do not think it is an area that is well researched.

CHAIR: Can I just pick up on that. Obviously, this committee will consider all the evidence we are given and make some recommendations that will then go to the health minister. Would you say that there should be some greater recognition of the sort of education you have been talking about in the national partnership agreement? Is that something that should be negotiated between the Commonwealth and the states?

Ms Floyd : Yes, I think it is, and I think it is something that the Commonwealth and the states could quite easily negotiate over. The states do do it; it is just about recognising how it would be counted. It might be counted in units of time spent, for example, delivering that antenatal class. But you also need to recognise that there is preparation time. A 30-minute session might have an hour of preparation, and in our case there might be three hours of driving time to get there and back to deliver the service.

CHAIR: Thanks very much.

Mr LYONS: Jut on the voucher system, how do you determine the value of a voucher? I presume you get a clinical costing—I do not know what the term is in dentistry—for a particular thing. Is it in your triaging that you determine what the value of that voucher is?

Ms Floyd : It varies. It could be in triage or it could be following clinical assessment by a dentist. For engagement with the private sector, we basically have three different types of vouchers that we issue. The first is an emergency voucher, which is for somebody who has a toothache. We have a set fee on that voucher. We have a set, limited range of item numbers that the dentist can provide and claim under that voucher. The fee that we pay is basically aligned with the Department of Veterans' Affairs fees and it is set by New South Wales Health. An emergency voucher could be done based on triage alone. A general voucher is where our dentist has assessed the patient and knows what treatment is needed and, if they give my administrative staff a list of what treatment is needed, they can approximately cost the value of the voucher and decide what it will be worth. For dentures, it is the same. For patients having a new full upper and lower denture, our denture voucher is around $1,560. That would cover that full upper and lower denture. It is less than most private dentists would charge their private patients. Certainly, in our part of the world, we have good participation from our private dentists, who are willing to provide a certain volume of care to patients with vouchers.

Mr LYONS: Thank you.

Mr IRONS: It was good of you to show us around this morning; I enjoyed the tour. You mentioned that there was not enough funding under either scheme, which is something we hear all the time, I guess. Without this type of facility, what would the oral health provision be like in this rural area now? What areas do you think could be improved on this model, if there are any improvements available besides funding?

Ms Floyd : It is important to be able to plan properly. I have been through lots of planning processes, and it is very hard to get the planners to put in extra space for what might happen, what might be funded. They only want to deal in the here and now. So we are very fortunate that we have this facility and the staff that we have at the moment, with the NPA coming in. Before we moved into this facility we were in Dubbo, in a four-chair clinic that was originally built as a school based clinic—a very small facility. I had been given funding by the state for additional positions, but I had nowhere to put those people. It is often a bit of a catch 22: you need the facility before you can employ the staff, but you cannot do any of that until you have the funding, and then funding comes and you are supposed to spend the funding this financial year. It is really challenging to be visionary and do things as well as you possibly can when you do not know what is around the corner. As I said earlier, particularly for dentistry, the states and the Commonwealth have engaged in blaming each other for many years.

I have colleagues who were around during the Commonwealth dental scheme, in the nineties, who had to live through the closure of that scheme. They had staff employed and they did not then have the funds to pay them and so on. Vouchers are in some ways the easy way to provide services, because you can turn on the tap and issue vouchers and you can turn it off again. I am sure it drives our private sector colleagues mad, because all of a sudden, out of the blue, you are issuing hundreds of vouchers. And then we stop. It makes it hard for them to manage their practices as well. If you have some certainty, you can actually do things in a more systematic and regulated way, and you can plan.

We were fortunate to get this building because Charles Sturt University had got their capital funding to build their facilities. We were able to leverage on top of that and negotiate to build a bigger building, where we could come together, and we were fortunate to get state funding for the capital for that. But that is not something you could count on at every opportunity that comes along.

Mr LYONS: You heard me ask about overseas trained people. Have you looked at recruiting anyone from overseas—what is your experience of that in the local area?

Ms Floyd : I actually have quite a bit of experience with that. I have a number of staff at the moment whose initial qualification was gained overseas. They have been the only people I could recruit over the last five or six years. It is only in the last 18 months that I have been able to recruit new graduates from Australia. Ideally, what we would like to see is people from the country who have completed their dental qualifications and will stay in the country. Certainly, some overseas qualified dentists are more willing to work and live in the country than some of the graduates from the universities in the capital cities.

Part of the problem is that they have to sit through the Australian Dental Council examinations to get their registration here. It is expensive, it takes time and it is very difficult for them to pass if they are not working in a dental environment. I still get phone calls from people who have overseas qualification. They are no doubt permanent residents of Australia and they would like to work for us, under supervision, so they can have a better chance of passing those exams. But employing people who have to be constantly supervised is difficult, especially when you are trying to provide outreach services.

One of the other things is that, in addition to someone being a very good clinician, we need people who work well in teams, who work well in the community and who have good communication skills. If someone has an overseas qualification but they have been working somewhere in Australia I can do some very thorough referee checks and decide on their suitability. But a lot of the overseas qualified dentists have not yet worked in Australia and it is very hard to assess those other skills in the workplace if you are talking to referees who perhaps do not have the same values as us in Australia.

Certainly, I have some wonderful staff. Adarsh, whom you met this morning on the tour, is an overseas-qualified dentist and he went through a program that NSW Health ran, called the International Dental Graduate program. His placement was in Port Macquarie, but I believe he went on a rural placement for six months as part of that program and stayed in the public sector and relocated to us. So that New South Wales scheme was very effective in finding people who were willing to work in the public sector and work in rural areas. It was also resource intensive for us, because we had to supervise them constantly for six months on placement.

The other problem was that as we were able to recruit those people at the end of the program and our vacancies were filled I did not have spare dental chairs to take more placements. And because of the increasing number of Australian graduates we are now expecting, that program has been closed. It was seen as a medium-term measure that met the need but that is no longer required.

Mr IRONS: With your first group of graduates now coming out, how many are in that group and how many are expected to stay in the rural area? Have you sat down and gone through their vocational expectations?

Ms Floyd : I have not, but Professor David Wilson will be here this afternoon and he can probably answer that question for you.

Mr IRONS: I will save it for him then.

Mr COULTON: Are you resourced enough for the holistic approach to dentistry, like preventative health, and what are your thoughts on the excessive use of soft drink and inappropriate diet in some of our children coming through, and how that is playing out in the oral health of the region? As a health district, are you implementing a holistic approach to dental control?

Ms Floyd : We are trying to but our resources are limited. We work in partnership with Bila Muuji, the consortium of Aboriginal medical services, to employ a regional oral health promotion coordinator, and I know that you are speaking to Bila Muuji later today. Soft drink consumption is a huge problem not just in the rural and remote communities but also in Dubbo and it is probably a problem in Sydney as well. It does need to be tackled. Our priorities—not to take away from our priorities—are around obesity, falls prevention and tobacco use. They are very important, but oral health just does not seem to feature there.

The only ads we see on television are those that are paid for by the dental companies—which have important messages but they also obviously promote the use of their products—whereas the message we need to get out there is that if you must drink soft drink only have it at meal times, do not have it in between and, for heaven's sake, do not sip on it all day. Cordial is full of sugar as well. Babies and children should drink water. Those messages need to get out there. That does not mean people have to buy anything to improve their health. Obviously people need to brush their teeth twice a day and use a fluoride toothpaste. That is an important message too and we really do not know how well understood that is in the community. One thing about our rural and remote communities is that the affordability of the toothbrush and toothpaste is a huge problem.

CHAIR: They are not cheap.

Ms Floyd : They are not—and they are very expensive in Wilcannia, as one example.

CHAIR: I would like to go to some of the reforms—the Dental Health Reform package—and get your thoughts on some of the initiatives that are out there. Obviously we have talked about the national partnership agreements and how that is having an impact. We have the Grow Up Smiling program that will replace the Teen Dental Plan. You comment on that would be quite useful.

Ms Floyd : The idea of a capitation or entitlement type scheme for children is an excellent idea. Under the teen dental program, the children could go and have a check and get some of those preventive items—that were perhaps a bit hard to know whether they had got or not—but if they had treatment needs and could not afford them then they had to come back and rely on the public dental system. I imagine what will happen with Grow Up Smiling is that patients who cannot afford the gap will still use the public dental service, in most cases, but at least there will be revenue for our service and, if the demand is there, we can grow our service because there will be a funding stream for that. But it will also mean that all children who have access to services can access them. I think that is a very important scheme and we are looking forward to seeing it implemented. It will be a challenge for us because, except for a little under the teen dental scheme, we have not been a Medicare funded service so it will have administrative challenges for us. Usually under those sorts of schemes, we have to claim everything under a single provider. I do not understand the ins and outs of Medicare and what can and cannot be changed, but when an organisation provides services I do struggle with why the revenue has to go to an individual with a provider number and why it cannot go to an organisation.

CHAIR: That is the way it works. It is built against providers.

Ms Floyd : Half of my clinical workforce cannot have provider numbers either because they are dental or oral health therapists, who do not currently have provider numbers.

Mr IRONS: In your organisation, who would you make the responsible person? How would you do that?

Ms Floyd : We would usually choose the most senior clinician, if they are agreeable, to take on that responsibility.

Mr IRONS: I like the idea but I worry how you would control that. If that senior clinician has not seen the patient, how would you link it?

Ms Floyd : We operated under the rules that Medicare said we could operate under and that was having a representative public provider. That was how we had to do it under the Medicare teen dental scheme; we did not have a choice. And we had to choose. By being that representative public provider, even though you do not see the money it has tax implications I understand. So it is not necessarily something that you would take on voluntarily, so then New South Wales Health had to implement an additional payment to those people, I guess, for the inconvenience that it may have. New South Wales Health dealt with that and I assume all the other states did as well. But under Grow Up Smiling, obviously the revenue that we are talking about is going to be significantly higher.

CHAIR: Yes. I think there are some models around that work in the medical health area and the committee might have a look at those to see whether they could work with Grow Up Smiling—some after-hours services and other programs. There might be something we can look at there. You make a valid point. The other one you might like to comment on is the flexible grants program that is going to provide dental infrastructure to rural, remote and outer metropolitan areas. Do you think that will be of benefit? It is not only for capital works; it will also link into money for the workforce. Would you like to comment on that?

Ms Floyd : I think that is very important. I have worked over the years with a number of local councils that have said on the one hand that dental care is not their responsibility, but on the other hand have asked how they are going to get a dentist. No-one is going to invest in capital in a rural area when they know that the chance of selling their practice is zero. Often have to walk away from that practice or they are lucky if they can just find a new dentist to walk in and take over. To set up a dental clinic obviously there is infrastructure involved; more than, say, a medical practice. Dental chairs, X-ray units, sterilising equipment and all the rest of it are required.

The grants idea is a great idea. My concern would be to make sure that it runs long enough. I do not think we have a lot of people right now who would move to rural areas, or perhaps they will but they will not stay very long. I would hope that in four or five years—for example, when this first group of CSU students have graduated and have enough experience to feel that they could work in a country town and be the only dentist in town—that would still be available if they need it. I am not sure whether it is in scope or not but local governments have been proactive. Gilgandra Shire Council that Mark mentioned earlier has been very proactive and has led the way to getting that two-chair dental clinic in that facility. I would hate to see them not included. If you give the money to individuals to relocate to rural areas and then they walk away, what happens? Sometimes that infrastructure is best owned by the community.

CHAIR: I suppose you feel similarly about the relocation and infrastructure grants that get dentists to relocate.

Ms Floyd : I have just mixed the two up. The comments I just made were really about the relocation and capital grants. When it comes to the flexible infrastructure funding, this building is a great example of what you can do, if you can access the funds to do it. That is very important. I am not sure how far it will go nationally. This building was over $8 million. It is obviously bigger than what some places would need. We certainly have areas where we really need new dental clinics and we will put in a bid for that funding.

Mr COULTON: Healthwise, Dubbo services figures of 190,000—or that is one figure that is bandied around. Is this clinic a clinic for western New South Wales or is it mainly being utilised by local Dubbo people?

Ms Floyd : It is being utilised by both. Any of our clients in western New South Wales Local Health District can go to any of our clinics wherever they can travel to and get their next appointment, but the reality is there are not many services west and north of here and we get patients from Bourke and Walgett. We have got patients who are travelling 700 or 800 kilometres return journeys to come and access dental care in Dubbo.

Mr COULTON: Just going back to something you said about five minutes ago, and Peter Muller touched on earlier: with medical students there is an internship and a program going through. I understand with dentists, once they become qualified, if they are brave enough, they could set up a practice from day one. Is there an opening, a possibility or a need for some form of internship in the dental education program so that there was an obligation that they did work with another dentist for some time—a year or two—before they become fully qualified?

CHAIR: I was going to ask about the voluntary dental graduate program that is a 12-month program and I think we have got 50 graduates this year going up to 75 next year, which links in a little with that. Maybe you can answer the two questions together.

Ms Floyd : I can; they are obviously connected. I might just answer what Mark asked first. It has been talked about in the profession that perhaps there should be an internship year for both dentists and oral health therapists. The big barrier initially was that there were state based registration, so each state would say that if we did it our graduates would just go interstate where they do not have to do an internship. Now we have national registration and that barrier has gone. I do not know if everyone in the dental profession supports it, but I find it hard to understand where, in almost every other registered health profession, you have to do an internship when you graduate why dentistry manages to still avoid it. I do not really think that new graduates are ready to practise independently and that they should have to go and practise in a practice where there is adequate mentoring—not necessarily day-to-day supervision by another dentist in the building every day but in a structured work relationship for at least 12 months, if not two years, that would not have to be in the public sector necessarily.

The voluntary dental graduate year program is a very structured and supportive program. We bid for two interns and we got one. We have a lovely young dentist at Mudgee. So we will be able to buy the extra instruments and things that we would need to employ another dentist. It did not cover the cost of a dental assistant for that dentist, so we did still have to find money in order to take on that graduate.

It is a lovely program and very structured. They do four days clinical per week and they have one day to work on study type things as part of the program. They get a bonus at the end of it. Anecdotally, I have heard that other people have been inquiring about whether they might be able to go to, say, Mudgee in that program.

So I think that voluntary dental graduate year program is working very well, but it is a little resource intensive. We are putting a lot of effort and goodwill into it and I do not think we could do it at that level for every graduate in Australia, but I certainly believe that graduates of dental programs should have to do a structured year before they can get their full registration.

CHAIR: Thank you very much for that fantastic evidence. It will be very useful.

Ms Floyd : Thank you very much for the opportunity to speak to you, and thank you for bringing your inquiry to Dubbo. It has made us very proud.

Proceedings suspended from 12:26 to 13:01